Patient Situation

Discuss about the Critical Reasoning Cycle.

Clinical reasoning cycle helps a nurse to critically analyze a patient’s situation and accordingly relate her knowledge of nursing to it. This is then followed by the introduction of evidence based interventions in the care plan for the patient, which includes goals, actions and evaluation of outcomes (Forsberg, 2016). Often handling opioid tolerant patients becomes difficult for those nurses who have not been exposed prior to such a situation as treatment of opioid tolerant patient after surgery is different form opioiod naïve patients. Hence, it is important for a nurse to develop prior knowledge of handling such patients and apply the correct ethical considerations when caring for the patient. The present assignment will highlight how a nurse totally ignored the condition of opioid tolerance patient and how she reflected the errors she made and leant form her mistake. This assignment will also contain the ethics required to handle such patients and provide effective treatment.

A 60 year old lady was admitted in the ward after she had a fall in her garden when she was having an evening walk in assistance with her grandson of 14 years old. She was admitted to the ward with a fractured knee and was instructed for  a knee arthroplasty. She was obese and was also suffering from immense pain due to her osteoarthritis. She was aged; the doctor had instructed her not to go for knee arthroplasty and therefore she had to undergo extensive pain in her knees. The medications that were provided to her could not give her relied form the pain and the doctor had to continually change her medication to long affecting opioid to give her relief on her request. She remains depressed and often cries because of her inability to move. He son had now requested the doctor to undertake knee arthroplasty to which his mother had also provided consent. She is a lover of fast food and requests her son to bring such food every day, her son could not deny thinking his mother may feel bad. She also does not take any exercise and have recently started taking walks in lawns half heartedly on advice of her son. She is on opioid treatment.

Clinical reasoning cycle helps the healthcare professionals by proving them to use it as a tool which helps them to collect cues, process the information and thereby come to an understanding of the patient problem or the situation. This would be then followed by making a proper plan followed by the implementation of interventions as well as evaluation of outcomes (Liou, Liu, Tsai, Tsai, Lin, & Chang, 2016). The nurse would then reflect upon the experiences so that she can apply the learning to net similar cases in her practice tenure in her professional life.

Steps Involved in the Cycle

The first step in a critical reasoning cycle is considering the patient situation. This mainly involves description as well as the list of facts, contexts, objects and people (Koivisto, Multisilta, & Katajisto, 2016). The patient is aged and is offerings form obesity as well as osteoarthritis. She is a lover of fast foods and do not want to take any exercise regime. She is also suffering from restricted mobility and has developed a sense of depression because of her loss of independence. She cannot perform her activities by herself which keep her depressed.

The next step involves the collection of cues and information of the patients. This step mainly involves reviewing current information, gathering new information and also recalling the knowledge (Hunter, 2016). She has faced a fall and had fractured her knees. The doctor has prescribed her to undergo for knee arthroplasty as there has been no other option to it. Her cause of development of obesity is mainly because of her inappropriate lifestyles, like having calorigenic fast food and lack or p[roper exercises. Her development of depression is mainly because of her lost of independence. Moreover her body weight is also affecting her conditions of osteoarthritis. Her knee arthroplasty will help her to overcome the pain to some extent and would be one of the contributor to her develop her quality of life.

The next step is processing of the information which includes the nurses to interpret, discriminate, relate, infer and match the situation with past references. This would be followed by prediction phase (Dalton & Gee, 2015). Here it is seen that the patient is not at all concerned about her own body weight and cannot realize the negative aspects related with her taking of fast food. She does not possess any health literacy and therefore she is unable to understand the pathopshysilogy of her gaining weight. Moreover she is also not having any idea about how her lack of enthusiasm to perform exercises is affecting her health. All these had resulted in heavy weight which is creating an additional pressure in her knees and worsening the condition of osteoarthritis. However her osteoarthritis is mainly due to the wear and tear of the cartilages that had taken place over the years and her love for remaining independence state that she was an ardent worker in the past in her young age (Kao & Tsai, 2014). Therefore she is not being able to cope up with the change in the lifestyles.

Establishing Goals and Taking Action

The next stage is synthesis of the facts and the inferences to identify the problem and thereby make a proper diagnosis. From the previous steps, it is seen that there obesity of the patient is creating an extra stress on her osteoarthritis condition. It is very important to make her correct her body weight as this might still create issues even when she undergoes knee arthroplasty as her knees might face extra pressure due to her body weight (Loew, Kenny, Durand-Bush, Poitras, & Wells, 2014). Moreover she should be allowed to undertake therapies with counselor like interpersonal therapy as well as cognitive behavioral therapy. All these are important for her to develop a better quality life.

The next stages are the establishment of goal and then taking appropriate action for them. The first goal would be to provide her with preoperative education with her knee arthroplasty surgery so that she can be well prepared with the situation and cope up with the situation so that she feels less stressed after the operation. For this the action that should be taken is to make her proper appointments of classes of preoperative education. The second goal would be to fix up a meeting with a dietician who would be providing her with her health education and give her a proper diet which would be helpful for her to stick to a low calorie diet. A proper exercise regime would be set for her who she would need to take to maintain her weight and also to develop her mobility (Tanaka, Ozawa, & Kito, 2016). The third goal and action to be taken is to make her free from her depression and for that the patient should be prescribed to meet with a counselor and also undertake cognitive behavioral therapy and also interpersonal therapy. Proper medication administration should be continued as per the medication so that her health condition is gradually made stable.

The next step is the evaluation of outcomes. In each of the action, the nurse should take the responsibility of proper assessment at interval of 12 hours in order to check that each and every goals and actions that she had implemented are bringing in best results in the patient (Williams, 2015). f any of the actions are not bringing positive results, then the nurse should modify the action at once so that her length of day in the hospital is not increased and she can experience better health as much faster as possible.

Evaluation of Outcomes

The eight step of the clinical reasoning cycle would be the reflection phase where the nurse or the healthcare professional needs to reflect on her own practice in order to learn from her mistakes and to handle the cases in amore better way form the nest time onwards. I came to know a very crucial fact form the handling of the patient which I was not at all aware before. The patient was opioid tolerant and I never took this fact into consideration while planning my critical reasoning cycle. I was severely criticized by my nursing mentor for the error I made while providing her with the opioid post treatment.  I had never handled any cases of opioid tolerant patient before and therefore I never knew of the consequences which might occur if I provide similar opioid medication to an opioid tolerant patient post surgery in comparison to that of opioid naïve persons. As I had provided a normal course of opioid medication provided to all patients, I had provided the dame medication to the patient. However, the patient started to shout aloud in pain and on assessment of the pain management scale, it was seen that her score was 9/10. Seeing this, the mentor arrived immediately and asked me to follow the procedure required to take for opioid tolerant patient. She taught me that as the patient had been staying on long acting opioid for long time due to her pain of osteoarthritis, the medications are not acting for her and as a result her sensation of pain is very high. Ketamine in low sub anesthetic doses are helpful in acting primarily as the non competitive antagonist of NMDA receptors (Vaid, Green, & Shinkaruk, 2016). Therefore I have leant that post operative administration of ketamine in opioid tolerant patients can lead to improved pain scores as well as decreased opioid concentration. The patient is now addicted to opioid and for this, the medication would be highly beneficial. This should be administered in the form of low dose in IV or SC infusion (Pasero, Quinlan-Colwell, Rae, & Broglio, 2016). Moreover I had actually provided under-medication and therefore the patient’s pain score was quite high. The medication which can bring positive effect is the transdermal fentanyl “patches”. Moreover after surgery, I have also learnt that transition form an intravenous or epidural to an oral opioid regime needs special attention from healthcare professionals in opioid tolerant patients. They need to have opioids for a prolonged period of time via intravenous or epidural route when compared with opioid-naive patients. Transition period to oral medication of opiod will need time and monitoring of sedation should be maintained as well. The first 24 to 48 hours need the patient to be associated with intravenous opioids via PCA after which oral medication doses can be started.

Reflection Phase

The first ethics that the nurses should keep in mind during the management is opioid tolerant patients is providing the patient with the scope of autonomy and dignity. A patient should be given the chance of expressing their own concern, fear, anxiety as well as the stress they are experiencing. It is the responsibility of the nurse to address the patients’ concerns and take appropriate interventions accordingly (de Koning, Penninx, Elders, Heijboer, Smit, & … & Lips, 2015) . This will help the patent to report better satisfaction after the treatment and this will also ensure the nurse to develop the linking, disliking, important facts and incidences about the patient which can help her in the long run. Another ethics that the nurse should follow is the provision of the safest intervention in order to ensure that the patient is free from any sort of threats (Krokmyrdal, 2015). The nurse should be responsible enough to take proper assessment of the patient’ history about the intake of opioids and be prepared prior to any surgical advancements. This would ensure the best care to the patient where the patient would not have to go through severe pain in any stage of the treatment. This ethics is based on the principle of beneficence where it becomes the duty of the nurse to provide the best practice to that of the patients. The third ethics that the nurse should also ensure is that she herself is free from any sort of bias and emotion. The nurses should strictly adhere to the guidelines of ethics which will help her to provide the best, unemotional, practical way of treatment and care which would be free from biasness and emotions (Bockhold, 2016). This should be irrespective of the caste creed, religion as well as culture of the patient. These factors should never influence the decisions and the pattern of care for the patient. This is based on the principle of justice.

From the above assignment, it was found that how clinical reasoning cycle helped the nurse to handle the patient situation effectively. It helped the nurse to establish the link that is present between the different co morbid disorders and how each of them have been affecting her present conditions leading to a poor quality life. Not only her physical condition, but her mental condition was also analyzed with establishment of proper care plan. However, the refection phase helped to identify the mistake that had been conducted by the nurse. She had completely no idea those opioid resistant patient require different sides of medication as the normal pain medication does not bring them proper results. With the help of the mentor, she was able to learn the procedure. The important ethics, of maintaining the patient’s autonomy, providing the best and safest intervention by beneficence and providing an unbiased care with the principle of justice are the three ethics which should be maintained by the nurse for treatment of the opioid naïve patients. This would help her to protect herself form ethical and legal obligations.

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